Probability Of Obstructive Coronary Artery Disease Research Articles

Coronary Artery Calciumscore As A Gatekeeper For Further Testing In Patients With Low Probability Ofobstructive Coronary Artery Disease: A Cost-effectiveness Analysis

Coronary Artery Calciumscore As A Gatekeeper For Further Testing In Patients With Low Probability Ofobstructive Coronary Artery Disease: A Cost-effectiveness Analysis

Stress echocardiography vs coronary oomputed tomography angiography for the detection of obstructive coronary artery disease in patients aged >70 years with suspected stable coronary artery disease

Aim. To compare stress echocardiography and coronary computed tomography angiography (CCTA) in the diagnosis of stable coronary artery disease (CAD) in patients aged >70 years.Materials and methods. The study included 390 patients aged >70 years with suspected stable CAD, which underwent elective coronary artery angiography (CAG). Initially, patients for whom stress echocardiography and CCTA is appropriate was determined. After that diagnostic accuracy of both methods in the detection of obstructive CAD was evaluated in patients with atypical angina and non-anginal chest pain.Results. Among 111 patients with atypical angina and non-anginal pain which underwent stress echocardiography and had unequivocal results, 69 (62 %) patients had obstructive CAD. Stress echocardiography has sensitivity of 89%, specificity of 95%, positive likelihood ratio (LR+) of 17,8, and negative likelihood ratio (LR-) of 0,1. Positive result increased probability of obstructive CAD from 62% to 95%, while negative result reduced probability to 16%. Among 82 patients with atypical angina and non-anginal pain which underwent CCTA, 48 (59 %) patients had obstructive CAD. CCTA has sensitivity of 100 %, specificity of 88%, LR+ of 8,3, and LR- of 0,3. Positive result increased post-test probability of obstructive CAD from 59% to 86%, while negative result reduced post-test probability to 0%.Conclusion. Stress echocardiography and CCTA has comparable diagnostic accuracy in the detection of obstructive CAD in patients aged >70 years with atypical angina and non-anginal pain. Stress echocardiography has a greater diagnostic value of positive result; CCTA has a greater diagnostic value of negative result.

Role of global longitudinal strain diastolic index in assessment of patients with suspected obstructive coronary artery disease and normal or mildly reduced ejection fraction

Objective – To examine the utility of global longitudinal strain imaging diastolic index (SI-DI) in the assessment of patients with suspected obstructive coronary artery disease (CAD). Methods – We performed rest 2D standard echocardiography and strain imaging in 30 healthy subjects and in 148 patients with normal or mildly reduced ejection fraction and indication for coronarography for suspected obstructive CAD. Standard echocardiographic and strain parameters were analysed. Results – Global SI-DI was signifi cantly lower in the selected vs control group (p <0.001). After coronarography patients were divided in three subgroups: 74 patients with more than 50% obstruction in any major artery, 26 patients with previous revascularisation but no significant obstructive lesions at present and 48 patients without obstructive artery disease. Average global SI-DI was significantly lower in the subgroup with obstructive CAD vs the other two subgroups (p<0.05). Global SI-DI lower than 0.5 had a good sensitivity (84%) and a reasonable positive predictive value (52%) for detection of obstructive CAD. Conclusions – Global SI-DI is significantly lower in patients with obstructive CAD and normal or mildly reduced ejection fraction compared with normal subjects. A cut off value lower than 0.5 selects patients with a higher probability of obstructive CAD.

A Novel Laboratory-Based Model to Predict the Presence of Obstructive Coronary Artery Disease.

Commonly used tools to assess the probability of obstructive-coronary artery disease (CAD) were derived based on Caucasian cohorts, with their performance in China is still unknown. Furthermore, most were established based on non-laboratory variables, contributing to the limited predictive ability to some extent. Thus, we developed and internally validated a laboratory-based model with data from a Chinese cohort of 8963 inpatients, with suspected stable chest pain, referred to catheter-based coronary angiography (CAG) from September 2007 to April 2019, and then compared the present model's performance with the four most commonly used prediction tools, Coronary Artery Disease Consortium 1/2 Score (CAD1/2), Duke clinical score (DCS), and Diamond-Forrester score (DF). The final model was developed by random forest method, including 8 predictors derived from 70 variables. Five-fold cross-validation was performed to evaluate the model's prediction accuracy. In the external validation set, the present model showed a superior area under the receiver-operating curve (0.816), followed by DCS (0.66), CAD2 (0.61), CAD1 (0.59) and at last DF (0.58), respectively. Furthermore, the present model correctly classified 74.4% of obstructive-CAD patients as high-risk, and correctly classified more than one third of non-obstructive-CAD patients as low-risk. The present model's net reclassification improvement (NRI) showed a significant positive reclassification over CAD1 (NRI = 0.60, P < 0.001), DF (NRI = 0.59, P < 0.001), CAD2 (NRI = 0.57, P < 0.001), and DCS (NRI = 0.43, P < 0.001). Decision curve analysis demonstrated that the present model provided a larger net benefit compared with CAD1/2, DCS, and DF. In conclusion, the novel model, using 8 laboratory and non-laboratory variables, performed well in risk stratifying patients with suspected chest pain regarding the presence of obstructive-CAD in the present Chinese cohort.

The Diagnostic Accuracy of Сoronary Сomputed Tomography Angiography in the Diagnosis of Stable Coronary Artery Disease in Patients Aged 70 Years and Older

The purpose of this study was to evaluate the diagnostic accuracy of сoronary сomputed tomography angiography (CCTA) in the diagnosis of stable coronary artery disease (CAD) in patients aged ≥70 years. The study included 390 patients aged ≥70 years with symptoms suggested stable CAD which underwent elective coronary artery angiography (CAG). Initially the prevalence of angiographically significant CAD was estimated according to the gender and chest pain character, and identifications of patients in whom CCTA was appropriate. After that diagnostic accuracy and сost-efficiency of CCTA in the diagnosis of stable CAD in 82 patients with atypical angina and non-anginal chest pain were evaluated. The prevalence of obstructive CAD in patients with typical angina was very high and they were excluded from the final analysis. Among 82 patients with atypical angina and non-anginal pain which underwent CCTA 48 (59%) patients had obstructive CAD. CСTA data matched with results of CAG in all cases. Among 34 patients that had non-obstructive CAD the results of CCTA and CAG matched in 88% cases. CCTA has sensitivity, specificity, positive predictive value, negative predictive value of 100%, 88%, 92% and 100% respectively. The likelihood ratio for positive result was 8.3, likelihood ratio for negative result was 0.3. Positive result increased post-test probabilityof obstructive CAD from 42% to 86%, negative result reduced post-test probabilityof obstructive CAD to 0%. negative CCTA result in patients aged 70 years and older with atypical angina and non-anginal pain allows to exclude the presence of obstructive CAD. The likelihood ratio for positive result indicates a moderately difference between the pre-test and post-test probability of the presence of obstructive CAD. In patients aged ≥70 years with atypical angina or non-anginal chest pain which have inconclusive results of functional testing or unable undergo functional testing CCTA allows to increase diagnostic yield of CAG and reduce the frequency of minor complications and diagnostic evaluation costs.

The Diagnostic Accuracy of Exercise Treadmill Testing and Stress Echocardiography for the Detection of Obstructive Coronary Artery Disease in Patients Aged ≥ 70 Years

to compare diagnostic accuracy of exercise treadmill testing and stress echocardiography in the diagnosis of stable coronary artery disease (CAD) in patients aged &gt;70 years. The study included 390 patients aged &gt;70 years with suspected stable ischemic heart disease, who underwent elective coronary artery angiography (CAG). Exercise treadmill testing (ETT) according to the modified Bruce protocol was carried out in 189 patients (48 %), bicycle stress echocardiography - in 179 patients (46 %). Initially we determined the prevalence of angiographically significant CAD according to the gender and chest pain character, and identified persons in whom stress testing was appropriate. After that diagnostic accuracy of both tests was evaluated in patients with atypical angina and non-anginal chest pain. Among 72 patients with atypical angina and non-anginal pain who underwent ETT and had unequivocal results, 38 (53 %) had obstructive CAD. ETT for detection of obstructive CAD had sensitivity 79 %, specificity 82 %, positive likelihood ratio (LR+) 4.4, and negative likelihood ratio (LR-) 0.3. Positive result increased probability of obstructive CAD from 53 % to 83 %, negative result reduced probability of obstructive CAD to 25 %. Among 111 patients with atypical angina and non-anginal pain who underwent stress echocardiography and had unequivocal results, 69 (62 %) had obstructive CAD. Sensitivity, specificity, LR+, and LR- of stress echocardiography were equal to 89 %, 95 %, 17.8, and 0.1, respectively. Positive result increased probability of obstructive CAD from 62 % to 95 %, negative result reduced probability of obstructive CAD to 16 %. bicycle stress echocardiography was found to be more accurate than ETT to rule in or rule out obstructive CAD in patients aged ≥ 70 years with atypical angina and non-anginal pain.

P2722Optimizing diagnosis of obstrutive coronary artery disease by CT angiography and ischemia test: a randomized clinical trial

Abstract Aim In patients with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) may improve patient selection for invasive coronary angiography (ICA) as alternative to functional testing. However, the role of CTA in symptomatic patients after abnormal functional test is incompletely defined. Methods and results This randomized clinical trial conducted in single academic tertiary center selected 218 symptomatic patients (pts) with mild to moderately abnormal functional test referred to invasive coronary to receive either the originally intended ICA (n=103) or CTA (n=115). CTA interpretation and subsequent care decisions were made by the clinical team. Patients with high risk features on functional tests, previous acute coronary syndrome, previously documented CAD, chronic kidney disease (GFR &lt;60 ml/min/1.73m2) or persistent atrial fibrillation were excluded. The primary endpoint was the percentage of ICA with no significant obstructive CAD (no stenosis ≥50%) in each group. Diagnostic and revascularization yields of ICA in either group were also assessed. Subjects averaged 68±9 years of age, 60% were male, 29% were diabetic. Nuclear perfusion stress test was used in 33.9% in CTA group and 31.1% in control group (p=0.655). Mean post (functional) test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 32.1%. In the CTA group, ICA angiography was cancelled by referring physicians in 83 of the pts (72.2%) after receiving CTA results. For those undergoing ICA, nonobstructive CAD was found in 5 pts (15.6%) in the CTA-guided arm and 60 (58.3%) in the usual care arm (P&lt;0.001). Mean cumulative radiation exposure related to diagnostic work up was similar in both groups (6±14 vs 5±14mSv, P=0.152), but a greater cumulative contrast dose in the CTA-guided group (87.5±21 vs 77±40, p=0.026) was observed. Both diagnostic (84.4% vs 41.7, p&lt;0.001) and revascularization (71.9% vs 38.8%, p=0.001) yields were significantly higher for CTA-guided ICA as compared to standard functional test-guided ICA. Conclusions In patients with suspected CAD and mild to moderately abnormal functional test, a diagnostic strategy including computed tomographic angiography as gatekeeper is effective and significantly improves diagnostic and revascularization yields of invasive coronary angiography.

Validity of Coronary Artery Disease Consortium Models for Predicting Obstructive Coronary Artery Disease & Cardiovascular Events in Patients with Acute Chest Pain Considered for Coronary Computed Tomographic Angiography

Although the majority of acute chest pain patients are diagnosed with noncardiac chest pain after noninvasive testing, identifying these low-risk patients before testing is challenging. The objective of this study was to validate the coronary artery disease (CAD) consortium models for predicting obstructive CAD and 30-day major adverse cardiovascular events (MACE) in acute chest pain patients considered for coronary computed tomography angiogram, as well as to determine the pretest probability threshold that identifies low-risk patients with <1% MACE. We studied 1,981 patients with no known CAD and negative initial troponin and electrocardiogram. We evaluated CAD consortium models (basic: age, sex, and chest pain type; clinical: basic + diabetes, hypertension, dyslipidemia, and smoking; and clinical + coronary calcium score [CAC] models) for prediction of obstructive CAD (≥50% stenosis on coronary CT angiogram) and 30-day MACE (Acute Myocardial Infarction, revascularization, and mortality). The C-statistic for predicting obstructive CAD was 0.77 (95% confidence interval [CI] 0.73 to 0.77) for the basic, 0.80 (95% CI 0.77 to 0.80) for the clinical, and 0.88 (95% CI 0.85 to 0.88) for the clinical + CAC models. The C-statistic for predicting 30-day MACE was 0.82 (95% CI 0.77 to 0.87) for the basic, 0.84 (95% CI 0.79 to 0.88) for the clinical, and 0.87 (95% CI 0.83 to 0.91) for the clinical + CAC models. In 47.3% of patients for whom the clinical model predicted ≤5% probability for obstructive CAD, the observed 30-day MACE was 0.53% (95% CI 0.07% to 0.999%); in the 66.9% of patients for whom the clinical + CAC model predicted ≤5% probability, the 30-day MACE was 0.75% (95% CI 0.29% to 1.22%). We propose a chest pain evaluation algorithm based on these models that classify 63.3% of patients as low risk with 0.56% (95% CI 0.15% to 0.97%) 30-day MACE. In conclusion, CAD consortium models have excellent diagnostic and prognostic value for acute chest pain patients and can safely identify a significant proportion of low-risk patients by achieving <1% missed 30-day MACE.

A simple prediction model to estimate obstructive coronary artery disease

BackgroundA simple noninvasive model to predict obstructive coronary artery disease (OCAD) may promote risk stratification and reduce the burden of coronary artery disease (CAD). This study aimed to develop pre-procedural, noninvasive prediction models that better estimate the probability of OCAD among patients with suspected CAD undergoing elective coronary angiography (CAG).MethodsWe included 1262 patients, who had reliable Framingham risk variable data, in a cohort without known CAD from a prospective registry of patients referred for elective CAG. We investigated pre-procedural OCAD (≥50% stenosis in at least one major coronary vessel based on CAG) predictors.ResultsA total of 945 (74.9%) participants had OCAD. The final modified Framingham scoring (MFS) model consisted of anemia, high-sensitivity C-reactive protein, left ventricular ejection fraction, and five Framingham factors (age, sex, total and high-density lipoprotein cholesterol, and hypertension). Bootstrap method (1000 times) revealed that the model demonstrated a good discriminative power (c statistic, 0.729 ± 0.0225; 95% CI, 0.69–0.77). MFS provided adequate goodness of fit (P = 0.43) and showed better performance than Framingham score (c statistic, 0.703 vs. 0.521; P < 0.001) in predicting OCAD, thereby identifying patients with high risks for OCAD (risk score ≥ 27) with ≥70% predictive value in 68.8% of subjects (range, 37.2–87.3% for low [≤17] and very high [≥41] risk scores).ConclusionOur data suggested that the simple MFS risk stratification tool, which is available in most primary-level clinics, showed good performance in estimating the probability of OCAD in relatively stable patients with suspected CAD; nevertheless, further validation is needed.

Abstract 9523: Comparison of Guideline Based Pretest Probability Scores Applied to Patients Undergoing Coronary Computed Angiography - The Partners Registry

Introduction: According to current guidelines, the initial test for the evaluation of coronary artery disease (CAD) in individuals with no known disease should be chosen according to the pre-test probability of obstructive CAD. While U.S. guidelines use the Diamond and Forrester (DF) classification, the recent European guidelines have proposed the use of other methods to estimate the pretest probability. Hypothesis: The performance of newer CAD prediction scores will be superior to the DF classification in patients referred to a coronary CTA. Methods: Exam findings were classified as non-obstructive (no CAD or &lt;50% stenosis) or obstructive (≥50%). For each individual we calculated a continuous version of the Diamond and Forrester score, the first version of the CAD consortium score (CAD1), and the two versions of the CAD consortium 2, the basic version (CAD2b), which includes the same variables as the DF classification, and a complete version (CAD2c), which also includes risk factors. We compared the calibration (predicted vs. observed prevalence of obstructive CAD) and discrimination (area under the ROC curves). Results: We included 2580 individuals (mean age 55±13 years, 58% males) with complete information on symptoms and risk factors needed to calculate the scores. 545 (21%) individuals had obstructive CAD on coronary CTA. The estimated probability of CAD by DF was higher than observed, especially among those with an intermediate-high pretest probability (Figure). When evaluating the discrimination, the c-statistic for the DF=0.718 (95%CI: 0.695 - 0.742), for CAD1= 0.7265 (0.703 - 0.750), for CAD2b =0.753 (0.730 - 0.776) and for the CAD2c = 0.791 (0.771 - 0.811). The CAD2c had a significantly higher c-statistic than the other models (p&lt;0.0001) Conclusions: The CAD2c provides better discrimination and calibration to predict obstructive CAD. Thus, the CAD consortium complete score should be preferred against current risk prediction strategies.

False positive results of SPECT - we should minimize the unnecessary referrals to invasive coronary angiography

Purpose: False positive (FP) results are common in single-photon emission computed tomography (SPECT) performed for obstructive coronary artery disease (OCAD) investigation. It is important to discriminate whether an ischemic result of SPECT is a FP, to avoid unnecessary referrals for invasive coronary angiography (ICA). We determined the clinical factors that were independently associated with a FP SPECT result. Methods: We analyzed a cohort of patients referred for ICA for stable coronary artery disease diagnosis, based on clinical judgment and a SPECT positive for ischemia, in a single tertiary-care center (2006-2011). Traditional and nontraditional coronary artery disease risk factors, modified Framingham risk score (FRS), symptoms, pre-test (SPECT) probability of OCAD, left ventricular ejection fraction and ICA results were assessed. OCAD was defined as any luminal narrowing ≥70%, or ≥50% for the left main artery. A FP SPECT was defined as reversible stress-induced perfusion defect and no OCAD. The predictors of a FP result were determined by the chi-square, exact Fisher and t-student tests when appropriate, and multivariate analysis (logistic regression). The discriminatory power for a FP result, of a model based on those predictive factors, was assessed by the area under the ROC curve (AUC) analysis. Results: 960 patients were included: 66.6±9.9 years, 58.1% male, mean 10-year Framingham risk 19.0%; 45.9% typical angina and 17.5% atypical angina; 55% high pre-test probability of OCAD; 13.6% depressed left ventricular ejection fraction (<55%). Globally, 51.0% of SPECT were FP results. The factors independently associated with a FP SPECT were: absence of severe angina (OR 6.1, 95% CI 2.1-17.4), absence of typical angina (OR 4.2, 95% CI 2.9-5.9), presence of atypical angina (OR 2.8, 95% CI 1.6-5.0), normal left ventricular ejection fraction (≥55%) (OR 2.5, 95% CI 1.7-3.5), female gender (OR 2.4, 95% CI 1.8-3.4) and lower FRS (OR 1.2, 95% CI 1.1-1.2), (all p<0.05). A model considering these factors together had good discriminatory power for predicting a FP result: AUC 0.80, 95% CI 0.78-0.83. Conclusions: Half of SPECT were FP in a population of patients referred for ICA following clinical judgment and a SPECT positive for ischemia. When analyzed together, the absence of severe angina/typical angina, the presence of atypical angina, normal left ventricular ejection fraction, female gender and lower FRS have good power for discriminating a FP result. These parameters should be given more relevance in order to avoid some unnecessary referrals for ICA.

Novel predictive model of obstructive coronary artery disease combining clinical and biohumoral data

Background: The probability of coronary artery disease (CAD) is currently estimated by the analysis of symptoms characteristics, age, sex, cardiovascular risk factors and stress tests. We sought to investigate the incremental diagnostic value of circulating biomarkers in reclassifying the probability of CAD. Methods: A total of 449 patients (60±9 years, 61% males) with angina-like chest pain or equivalent symptoms, enrolled in the EVINCI study, underwent clinical examination, exercise electrocardiogram, biohumoral characterization (36 biomarkers associated with atherosclerosis) and invasive coronary angiography. Primary end point was obstructive CAD, defined as >70% coronary stenosis in at least one major epicardial vessel, or 30-70% stenosis with fractional flow reserve ≤0.8. Diamond & Forrester (D&F) predictive model, including age, sex, type of symptoms and exercise ECG, was used as reference. A new model was built-up adding biohumoral variables selected by multivariate logistic regression to D&F variables. Diagnostic performance was assessed by the area under the Receiver Operating Characteristics curve (AUC) and the clinical utility by estimating net reclassification improvement (NRI), using 50% probability of CAD as cut-off. Results: The probability of obstructive CAD was 65% \[34-78%] by D&F model while the actual prevalence of the disease was 30%. High-density lipoprotein cholesterol, aspartate transaminase, homeostasis model assessment index, interleukin-6 and osteopontin were independent predictors of obstructive CAD at multivariate logistic regression. The addition of these biomarkers to D&F variables determined a significant increase of diagnostic accuracy [AUC from 0.72 (SE 0.03) to 0.82 (SE 0.03)\] (p <0.001). The integrated model allowed a correct reclassification of 18% of patients [NRI=18% (SE 0.05), p=0.001]. Conclusions: The D&F model overestimates the probability of obstructive CAD. Updating the model to a contemporary European population and adding biohumoral markers improves the predictive accuracy and correctly reclassifies a significant number of patients.

False positive results of treadmill exercise ECG - we should minimize the unnecessary referrals to invasive coronary angiography

Purpose: False positive (FP) results are common in treadmill exercise ECG testing (TMT) performed for obstructive coronary artery disease (OCAD) screening. It is important to discriminate whether an ischemic response in TMT is a FP result, to avoid unnecessary referrals for invasive coronary angiography (ICA). We determined the clinical factors that were independently associated with a TMT FP result. Methods: We analyzed a cohort of patients referred for ICA for stable coronary artery disease diagnosis, based on clinical judgment and a TMT positive for ischemia, in a single tertiary-care center (2006-2011). Traditional and nontraditional coronary artery disease risk factors, modified Framingham risk score, symptoms, pre-test (TMT) probability of OCAD, left ventricular ejection fraction and ICA results were assessed. OCAD was defined as any luminal narrowing ≥70%, or ≥50% for the left main artery. A FP TMT result was defined as an ischemic response (2006 TMT European Society of Cardiology guidelines) and no OCAD. The predictors of a FP result were determined by the chi-square, exact Fisher and t-student tests when appropriate, and multivariate analysis (logistic regression). The discriminatory power for a FP result, of a model based on those predictive factors, was assessed by the area under the ROC curve (AUC) analysis. Results: 1243 patients were included: 65.2±9.9 years, 63.0% male, mean 10-year Framingham risk 17.8%; 51.1% typical angina and 20.1% atypical angina; 65.4% high pre-test probability of OCAD; 4.3% depressed left ventricular ejection fraction (<55%). Globally, 51.6% of TMT were FP results. The factors independently associated with a FP TMT were: absence of severe angina (OR 22.0, 95% CI 5.3-91.2), presence of atypical angina (OR 17.3, 95% CI 9.4-31.6), absence of angina (OR 3.8, 95% CI 2.9-5.2), female gender (OR 2.4, 95% CI 1.8-3.3), non-smoking (OR 2.1, 95% CI 1.4-3.0), absence of diabetes (OR 1.5, 95% CI 1.1-2.0) and younger age (OR 1.1, 95% CI 1.0-1.1), (all p<0.05). A model considering these factors together had good discriminatory power for predicting a FP result: AUC 0.80, 95% CI 0.78-0.83. Conclusions: Half of positive TMT were FP in a population of patients referred for ICA following clinical judgment and a TMT positive for ischemia. When analyzed together, the absence of angina/severe angina, the presence of atypical angina, female gender, non-smoking, absence of diabetes and younger age have good power for discriminating a FP result. These parameters should be given more relevance in order to avoid some unnecessary referrals for ICA.

Abstract 251: Clinical Symptoms and Angiographic Findings of Patients Undergoing Percutaneous Coronary Intervention without Prior Stress Testing: Insights from the NCDR

Background: Many patients undergoing elective percutaneous coronary intervention (PCI) do not have prior stress testing. It is unknown if these patients have more severe angina or obstructive coronary artery disease (CAD), whereby proceeding directly to PCI would represent sound clinical judgment and efficient use of resources. Methods: We identified elective PCIs performed between 1/1/09 - 3/31/11 in the NCDR CathPCI Registry ® and assessed for differences in angina (CCS class) and severity of CAD in those with and without pre-procedural stress testing. To further understand whether proceeding to PCI without prior stress testing could be justified because of a high pre-test probability for obstructive CAD (e.g., &gt;70% stenosis in an epicardial coronary artery), we evaluated cardiac catheterizations performed within the registry during the same period to assess the diagnostic yield of obstructive CAD in patients with and without prior stress testing. Results: Of 246,629 elective PCIs, 89,084 (36.1%) were performed without prior stress testing. A substantial proportion of both groups undergoing PCI were asymptomatic (no stress test group: 28.9% vs. stress test group: 30.7%), with only a modest difference in the frequency of CCS class III/IV angina (16.2% vs. 11.9%; Table). No meaningful differences in the frequency of proximal LAD (29.7 % vs. 29.9%), left main (5.6% vs. 7.2%) or 3-vessel coronary artery disease (21.1% vs. 19.5%) were observed in the 2 PCI groups. Moreover, the diagnostic yield for obstructive CAD on cardiac catheterization for patients without prior stress testing (n=462,611) was 35.4%, as compared with 58.0%, 38.8%, and 24.1% for those with severe, moderate, and mild ischemia, on pre-procedural stress testing. Conclusion: For elective PCI, the current practice of proceeding to coronary angiography and PCI without prior stress testing does not identify higher risk coronary anatomy or more symptomatic patients and may not improve diagnostic yield.

Prognostic value of adenosine stress cardiovascular magnetic resonance and dobutamine stress echocardiography in patients with low-risk chest pain

Excluding obstructive coronary artery disease (CAD) as the etiology of acute chest pain in patients without diagnostic electrocardiographic changes or elevated serum cardiac biomarkers is challenging. Stress testing is a valuable risk-stratifying technique reserved for the subset of these patients with low-risk chest pain who have an intermediate clinical probability of obstructive CAD. Given the risks of radiation inherent to nuclear and computed tomography imaging, both adenosine stress cardiovascular magnetic resonance (AS-CMR) imaging and dobutamine stress echocardiography (DSE) are attractive alternative stress modalities. An essential characteristic of stress modalities is their negative prognostic value; as one must exclude clinically-relevant CAD such that patients can be discharged safely. Therefore, the aim of this study was to validate a favorable negative prognostic value for both AS-CMR and DSE in patients presenting with low-risk acute chest pain. This retrospective study included 255 patients with low-risk acute chest pain and no prior history of CAD presenting to the emergency department at our institution, with 89 patients evaluated by AS-CMR and 166 by DSE. Median follow-up was 292 days, and consisted of medical record review. The primary end-point was the composite of cardiac death, nonfatal acute myocardial infarction, obstructive CAD on invasive coronary angiography (ICA) or recurrent chest pain requiring hospital admission. Test characteristics such as sensitivity and specificity could not be evaluated as patients were not routinely evaluated with ICA. All patients completed the stress protocol without adverse events during testing. 82/89 patients (92.1%) and 164/166 patients (98.8%) had negative AS-CMR and DSE studies, respectively. Both AS-CMR and DSE had excellent negative prognostic values for the primary endpoint, 100 and 99%, respectively. Both AS-CMR and DSE are effective stress modalities for excluding clinically significant coronary artery disease in patients presenting acute low-risk chest pain. Patients without findings to suggest ischemia have an excellent intermediate-term prognosis.